Use of poly(2-hydroxyethyl methacrylate) for endovascular occlusion in pediatric surgery

Embolization using poly(2-hydroxyethyl methacrylate) (PHEMA) hydrogel particles, of cylindrical spherical form, was successfully achieved in 42 children treated for non-operable haemangiomas of the liver, and angiodysplasias. Spherical PHEMA hydrogels appeared to be the only possibility for the treatment of 26 children suffering from extensive cavernous haemangiomas of face and neck. Particles were able to cover the tumour, stop its growth and allow the use of local hyperthermia with the electromagnetic field. A partial two-stage embolization using beaded PHEMA was also used as part of the multistage treatment for curing the spleen in 28 children suffering from haemolytic spherocytic anaemia, thrombocytopenic purpura and portal hypertension.

Immune thrombocytopenic purpura and intravenous immunoglobulin

The observation, in 1980, of a rapid increase in platelet counts as a result of administration of intravenous immunoglobulin (IVIG) in a patient with immune thrombocytopenic purpura (ITP) was followed by clinical studies confirming the efficacy of this new treatment alternative in ITP. Simultaneously, new sensitive assays using monoclonal antibodies against platelet glycoproteins showed that chronic ITP in adults and children is often an autoimmune disorder. There seem to be both immediate and long-term effects of IVIG in ITP which may be explained by mechanisms of action other than immunoglobulin G substitution. The mode of action of IVIG could correspond to interference with Fc receptors on phagocytes or be a result of antiidiotypic antibodies in IVIG that may induce secondary changes in the complex immunologic network. These immunomodulatory effects were the basis for the use of IVIG in the treatment of patients with other immune-related disorders. New aspects regarding definition and treatment of ITP, the possible mechanisms of action of IVIG, and the implications thereof are discussed and updated.

[Therapy of immune thrombopenia]

Idiopathic thrombocytopenic purpura (ITP) belongs to the family of autoimmune diseases. The term "idiopathic", however, is no longer correct as it is in fact an immunologically-related thrombocytopenia. This is why nowadays it is referred to as immune thrombopenia. Clinically the acute and chronic forms of ITP can be distinguished. We discuss the different forms of treatment based upon data provided by various studies of ITP. If treatment with prednisone or with gammaglobulins fails, or after unsuccessful splenectomy, then alternative experimental therapies may have to be used. Some of these treatments are described with reference to their therapeutic benefit and their function.

Post-transfusion purpura

Post-transfusion purpura is a complication of blood product transfusion in which the recipient produces antiplatelet antibodies resulting in severe thrombocytopenia. The typical patient is a multiparous woman who develops sudden severe purpura 1 week after receiving a transfusion of packed red cells or whole blood. Post-transfusion purpura should, however, be considered in any patient with thrombocytopenia following infusion of a blood product. Untreated, the disease can be fatal or cause serious morbidity. Treatment options include plasmapheresis, intravenous immunoglobulin, and corticosteroids. Platelet transfusion is usually unsuccessful.

Intravenous anti-D treatment of immune thrombocytopenic purpura: analysis of efficacy, toxicity, and mechanism of effect

The efficacy, toxicity, and mechanism of effect of intravenous Anti-D (Winrho) were studied in 43 Rh+ patients with immune thrombocytopenia purpura (ITP) who had not undergone splenectomy and in three already splenectomized patients. The mean platelet increase for the 43 nonsplenectomized patients was 95,000/microL (median 43,000/microL). Children had greater acute platelet responses than did adults. Human immunodeficiency virus status and duration of thrombocytopenia did not affect response. Maintenance treatment was given to patients as needed: the average interval between infusions was 24 days. The three splenectomized patients had no platelet response whatsoever. Toxicity was minimal; infusions were completed in less than 5 minutes. The generally accepted mechanism of effect of Anti-D has been Fc receptor blockade by substitution of antibody-coated red blood cells for antibody-coated platelets. Evidence is presented suggesting that the effect of IV Anti-D is not limited to Fc receptor blockade, including: (1) no correlation of parameters of hemolysis with platelet increase; (2) a 48- to 72-hour delay before platelet increase; (3) a tendency of the change in monocyte Fc receptor I expression to correlate with platelet increase; and (4) increased in vitro production of antibodies to sheep red blood cells following IV Anti-D infusion.

Chronic idiopathic thrombocytopenic purpura (ITP) in adult Ethiopians: clinical findings and response to therapy

Between January 1982 and December 1989, thirty four cases of chronic idiopathic thrombocytopenic purpura (ITP) were seen in adult Ethiopians in the Department of Internal Medicine in-patient and haematology referral clinic, of Tikur Anbessa teaching hospital. Twenty three were females and eleven males; female to male ratio of 2.1:1. The age range was 13-57 years, with a mean of 24.9 years. The commonest manifestations were: purpura, epistaxis, gum-bleeding and menorrhagia. The duration of symptoms ranged from one month to over ten years (median 4.5 months). The platelet counts ranged from 4000/mm3 to 77,000/mm3 (mean - 19,200/mm3), haemoglobin 3.01 to 15.4 gm/dl (mean - 8.2 gm/dl). Four (11.8%) patients were not treated; of these, one went into spontaneous remission. Thirty patients (88.2%) were treated with prednisolone 1.0 to 1.5 mg/kg/day orally. Of these, 7 (23.3%) had excellent, 2 (6.7%) good, 6 (20%) fair, and 15 (50%) had poor responses. Ten patients had splenectomy with 5 (50%) excellent 2 (20%) good, 2 (20%) fair and 1 (10%) poor response. One patient with refractory ITP was treated with immunosuppressive drugs and had an excellent response. Fifteen patients are alive and on followup 3-122 months (median 33 months) after diagnosis, fifteen are lost after followup of 1-66 months (median 9 months) and four have died 1-18 months (median 2 months) after diagnosis. Chronic ITP is frequently seen in adult Ethiopians, its clinical features and response to therapy are similar to those reported in the literature.

Immune thrombocytopenia: surgical therapy and predictors of response

We have reviewed 40 patients with immune thrombocytopenia purpura (ITP) to assess current methods of preparation for surgery and to evaluate perioperative complications and response to splenectomy. Twenty-one patients had chronic ITP (greater than 1 year duration) and 19 patients had severe acute thrombocytopenia (platelet counts less than 10,000). A progression of methods of pretreatment was seen in the 10-year period reviewed. Seventeen patients received no treatment before admission for surgery, and 10 of these received platelet transfusions. Seventeen patients received steroids immediately preceding surgery; 16 of these responded and 1 received a platelet transfusion. Recently, 5 patients received intravenous gamma globulin (IgG) preceding surgery with all patients responding and none receiving platelet transfusions. One patient received a combination of steroids and IgG with good response and did not require platelet transfusion. No major postoperative complications occurred (ie, pancreatitis, small bowel obstruction, or sepsis) except for one patient requiring a secondary exploration for an accessory spleen and recurrent thrombocytopenia. Eight patients (20%), 6 with severe ITP and 2 with chronic ITP (5 males and 3 females) developed recurrence of thrombocytopenia following surgery up to 1 1/2 years after splenectomy. These patients all required further medical therapy. Three additional patients (2 chronic and 1 severe) developed thrombocytopenia following viral illnesses, but required no further therapy. Of the 8 surgical failures, 4 failed to respond to prior treatment with steroids, 1 to IgG, and 2 failed to respond to combination therapy, while one surgical failure responded to both steroid and combination therapy. Of the responders to splenectomy (32 patients), only 3 failed to respond to prior treatment with steroids.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV-related thrombocytopenia: a therapeutical update

HIV-seropositive patients who belong to the three major acquired immunodeficiency syndrome (AIDS) risk groups may develop an idiopathic thrombocytopenic purpura (ITP) which is related to the HIV infection. HIV-associated ITP clinically resembles classic ITP but, in spite of very low platelet numbers, bleeding is rarely severe, and moderate splenomegaly and lymphadenomegalies are seldom present. Treatment is the same as that given for classic ITP because the pathogenesis is in many ways similar. Immunosuppressors can be dangerous in the case of retrovirosis, and splenectomy may lead to AIDS. High doses of immunoglobulins often give an improved platelet count but this tends to be short-lived, and long-term periodical infusions usually lose therapeutical effect. Alpha interferon gives conflicting results and Danatrol is not usually effective. Specific anti-D immunoglobulins produce a high percentage of positive results and may be administered for long-term maintenance without side effects. Zidovudine (AZT) may produce a good platelet increase in a large number of patients, but there is no consensus for the use of this anti-retroviral drug in otherwise asymptomatic HIV-positive patients. In conclusion, since it is very unusual for bleeding to occur, moderate thrombocytopenia is best left untreated because a spontaneous increase in platelet count is possible. But if the platelet count is very low, or if bleeding is present, treatment is mandatory and must produce a rapid platelet increment with minimal side effects.

[Use of intravenous immunoglobulins in pediatrics]

Intramuscular Immunoglobulin (IMIG) have been used for 40 years in substitution therapy for antibody deficiencies and as prophylaxis for and treatment of several infectious diseases. Modified and intact intravenous immunoglobulin preparations (IVIG) have now been available for more than 10 years: only the intact product express full Fc- mediated functions with a biological half-life of IgG (3-4 weeks). These preparations have constituted an important achievement in the treatment of humoral immunodeficiencies also resulting in a dramatic improvement of the prognosis. The use of IVIG has also modified the therapeutic approach to several secondary and acquired immunodeficiencies. Treatment with IVIG for immune modulation in several diseases is investigated: substantial data indicate a useful role in selected cases of idiopathic thrombocytopenic purpura, Kawasaky disease and in some neurologic diseases. IVIG are substantially safe and severe side effects have been rarely reported.

Aseptic meningitis associated with high dose intravenous immunoglobulin therapy

Two cases of aseptic meningitis occurred in temporal association with high dose intravenous immunoglobulin therapy to treat thrombocytopenia. In neither case was any other aetiological agent identified and both patients completely recovered within a few days. This phenomenon has been reported in only one previous paediatric case.

High-dose immunoglobulin therapy in four patients with onyalai

Onyalai, a form of immune thrombocytopenia in Africa, has a recorded death rate of 9.8% in the acute phase due to haemorrhagic shock or central nervous system bleeding. Four patients with active bleeding and a mean platelet count of 6 x 10(9)/litre were each treated with 0.67 g/kg intravenous globulin (Sandoglobulin) daily on 3 successive days. Clinical bleeding ceased within 3 d and all patients responded with a rise in the platelet count, which peaked at 19-21 d. No side effect was recorded. Intravenous globulin therapy may reduce the morbidity of the acute phase of onyalai.

Late appearance of thrombotic thrombocytopenic purpura after autoimmune hemolytic anemia and in the course of chronic autoimmune thrombocytopenic purpura: two case reports

The association between thrombotic thrombocytopenic purpura (TTP) and autoimmune hematological conditions is reported in 2 patients. In a 35-year-old man, acute autoimmune hemolytic anemia (AIHA) was diagnosed in 1960; until 1965 he was free of disease, when he abruptly developed TTP and failed to respond to blood transfusions and corticosteroids. In a 14-year-old girl, autoimmune thrombocytopenic purpura (AITP) was diagnosed in 1981 and treated with corticosteroids and splenectomy. Four years later the patient was admitted with acute catastrophic signs and symptoms of TTP and failed to respond to plasmapheresis and plasma transfusions. The present case reports of associations between AIHA and AITP with TTP support the connection of the latter with abnormalities of the immune system.

Pregnancy in women with immune thrombocytopenic purpura

Thirty-six women with immune thrombocytopenic purpura were studied during 37 pregnancies, and maternal characteristics with predictive value for the fetal platelet count were determined. Nine neonates were thrombocytopenic, with a platelet count of less than 50 x 10(9)/L in eight. Four of these nine neonates delivered to a subgroup of 31 mothers were studied prospectively; the frequency of thrombocytopenia in neonates of women with immune thrombocytopenic purpura was thus 13%. Only two of these nine neonates presented with hemorrhagic syndromes (two, petechial purpura; one, intracranial bleeding). The frequency of neonatal thrombocytopenia was higher in mothers with deep thrombocytopenia and in those who had not responded to corticosteroid treatment following diagnosis. No prognostic value could be assigned to the other maternal characteristics studied, such as a history of splenectomy, maternal treatment at the time of delivery, or the presence of platelet autoantibodies evaluated either with the platelet immunofluorescence test or the platelet Western blot immunoassay.

[Pregnancy complicated with autoimmune diseases]

Autoimmune disorders such as SLE and ITP occur more commonly in young women and are the most common complications in pregnancy. There is considerable controversy concerning the risk to the mother and fetus, and the optimal prepartum management for minimizing that risk. 1. SLE is an autoimmune disorder in which IgG antibodies such as anti dsDNA-IgG, anticardiolipin IgG, and anti SS-A/Ro IgG are produced. Lupus nephropathy accompanied by diminished serum complement (CH50) and a rise in antibodies against dsDNA is a frequent clinical problem during pregnancy, which represents the adverse effect of hypertension or superimposed toxemia and causes fetal death or intrauterine fetal growth retardation. Habitual abortion or fetal death is common in a case with high anticardiolipin IgG titre. Anti SS-A antibodies are often found in the infants of antibody-positive mothers, and the deposition of antibodies in the perinodal region cause congenital heart block. IgG or immune complexes crossing the placenta directly injures the cardiac conduction system. In these cases which have high titre crossing the placenta directly injuries the cardiac conduction system. In these cases which have high titre of autoimmune antibodies, corticosteroid therapy should be started. 2. Management of ITP in pregnancy involves the consideration of three issues: 1) treatment of maternal thrombocytopenia, 2) prediction of fetal thrombocytopenia, 3) obstetrical management. ITP increases the risk for postpartum bleeding of sufficient severity to require blood transfusion. In most of these cases, maternal platelet counts are found to be less than 30,000/mm3. Women who have symptomatic severe steroid-unresponsive ITP may benefit from intravenous IgG(IvIgG) given as elective treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of chronic subdural hematoma associated with idiopathic thrombocytopenic purpura (ITP)]

A 41-year-old male was admitted to our service with right occipital pain as his chief complaint. CT and MRI examinations revealed bilateral chronic subdural hematomas. The patient had also been affected with ITP since the age of 28. Since emergency operation was thought to be dangerous, he was transferred to Tokushima University Hospital, and treated preoperatively by administration of steroids and a large dose of immunoglobulin. When his platelet count had returned to 146,000/mm3, evacuation of the hematoma through burr holes was performed successfully under local anesthesia. The postoperative course was uneventful. So far as we have been able to find in the literature, only 3 cases of ITP complicated by chronic subdural hematoma have been reported. The characteristic clinical feature of these 4 cases including our own case was noted as the absence of a history of trauma. However, the etiological relationship between ITP and chronic subdural hematoma was controversial. Occurrence of chronic subdural hematoma in patients with ITP and in patients under hemodialyzer treatment is very rare. However, intracerebral hemorrhages are rather common among such patients. So it was suggested that the tendency to bleeding among patients with ITP, and among hemodialyzer patients may contribute little as an etiological factor in the evolution of chronic subdural hematoma.

The frequency of platelet alloantibodies in pregnant women and the occurrence and management of neonatal alloimmune thrombocytopenic purpura

Neonatal alloimmune thrombocytopenic purpura (NAITP) is induced by maternal antibodies to fetal platelet alloantigens. The disease is rare, but is often responsible for intracranial hemorrhages leaving severe neurological damage. Although this occurrence is rare, its frequency may be underestimated. In order to determine the frequency of alloimmunization to platelet antigens, serum from pregnant women were investigated in platelet-ELISA and lymphocytotoxic test (LCT). Seventy-eight out of 556 pregnant women (14%) were found to have antibodies to platelet antigens in ELISA and/or LCT. In one case (0.18%) a platelet specific antibody, anti-Zwa(-PIA1), was found in the platelet-ELISA. In all of the other cases only HLA-antibodies were detected. The only mother who was delivered of a child with clinical NAITP was the woman with anti-Zwa(PIA1) in serum. Furthermore, in a review from the currently available literature the following items will be discussed: 1) human platelet antigens involved in NAITP, 2) clinical aspects and prognosis of NAITP, 3) immunological diagnosis of NAITP, and 4) prevention and treatment of the disease.